1. Choosing Wisely at Austin Health Lessons Learnt in An Australian Health Service

2. Background
Austin Health is tertiary academic public health service, which services its local catchment and also provides a number of state wide services. Austin operates 911 beds and employs over 8000 staff across three sites
The Choosing Wisely project at Austin Health was funded through the 2016/17 BCV Innovation Fund and delivered with support from NPS MedicineWise (Choosing Wisely Australia) and Eastern Health (NUTS program)

3. Choosing Wisely at Austin Health
Objectives:
Engage consumers, clinicians and hospital staff in the concept of “More is not always better” when it comes to medical tests, treatments and procedures
Empower health professionals to question what care is truly needed
Engender support for the project among key health services and non-medical stakeholders
Engage with other health services and healthcare providers in supporting the initiative and encourage implementation of the recommendations
Support clinicians to understand and engage in high quality evidence based practice
Encourage consumers to engage in conversations about their care with their healthcare providers

4. Project Governance Project Manager – 0.8 EFT
Four clinical leads (consultants) – 0.2 EFT each
Emergency Department / Quality & Audit
Medical Oncology
Anaesthetics / Pain Services
Gastroenterology / Medical Education
Multidisciplinary steering committee – Meeting monthly
Junior medical staff committee - Meeting bi-monthly
Additional resources:
Finance Department
Business Intelligence Unit
Clinical Informatics Team
Communications Team

5. Project Development

6. Topic Selection Core topic areas Coagulation Studies
Four key areas of behaviour change strategies undertaken for each topic area
Urine Cultures
De-prescribing
Opioids
PPIs

7. Topic Selection Core topic areas Coagulation Studies
Four key areas of behaviour change strategies undertaken for each topic area
Urine Cultures
De-prescribing
Opioids
PPIs

8. Topic Selection Secondary areas Febrile neutropenia management
Activities independently undertaken by the Choosing Wisely Clinical Leads with support from project team
CRP Ordering in ED
Lower back imaging in ED
Colonoscopy preparation
End of Life Care
CT Imaging for Low Risk PE

9. Problem Identification
Coagulation Studies
Problem Identification
Anecdotal evidence from senior clinicians that there is a high volume of Coagulation Studies ordered inappropriately
WHY?
Coags = INR, APTT, Fibrinogen and PT as a group
Clinicians ordering coags when only INR needed
Coags being on the list of high frequency tests on electronic ordering system
What are the financial benefits realised during this time?

10. Baseline Data Coagulation Studies
What are the financial benefits realised during this time?

11. Behaviour Change Strategies
Coagulation Studies
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Regression modelling of factors associated with multiple test ordering

12. Behaviour Change Strategies
Coagulation Studies
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Regression modelling of factors associated with multiple test ordering
Policy & Guidelines
Development of new pathology guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system

13. Behaviour Change Strategies
Coagulation Studies
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Regression modelling of factors associated with multiple test ordering
Education & Peer Support
Lunch time education sessions
Grand round presentations
Presentations to external groups
Intranet information campaigns
Links to publications and resources
Policy & Guidelines
Development of new pathology guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system

14. Behaviour Change Strategies
Coagulation Studies
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Regression modelling of factors associated with multiple test ordering
Education & Peer Support
Lunch time education sessions
Grand round presentations
Presentations to external groups
Intranet information campaigns
Links to publications and resources
Policy & Guidelines
Development of new pathology guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system
Informatics
Pop-up messaging with the ordering of Coagulation Studies on CERNER
Removal of Coags group from list of Common Tests
Splitting of Coags group

15. Coagulation Studies
Decision Support Tool

16. Coagulation Studies
Feedback Reports

17. Promotional Strategies
Coagulation Studies
Promotional Strategies

18. Results – ED Coagulation Studies
What are the financial benefits realised during this time?

19. Results – Hospital Wide
Coagulation Studies
Results – Hospital Wide
What are the financial benefits realised during this time?

20. Results Coagulation Studies Pre-intervention Post-intervention
Volume of tests across whole hospital
Weekly mean =
Weekly mean =
↓ p<0.05
Volume of tests in ED
Weekly mean =
Weekly mean = 49.39
Volume of tests per patient whole hospital
0.27
0.16
↓ 39.9%
Volume of tests per patient in ED
0.07
0.01
↓ 81.4%
Pathology costs per patient whole hospital (inpatient and ED)
↓ $75 per patient episode
Total potential savings of $191,025
Audit: Indications for coagulation study ordering
↓ 4 out 5 audit units reported a decrease in orders with no indication
What are the financial benefits realised during this time?

21. High volume coagulation study ordering
Coagulation Studies
Results
High volume coagulation study ordering
Number of admissions
Number of prescribers
Number of wards
Average variation of INR from normal range
Average variation of APTT from normal range
Average variation of Fibrinogen from normal range
Average variation of PT from normal range
What are the financial benefits realised during this time?

22. High volume coagulation study ordering
Coagulation Studies
Results
High volume coagulation study ordering
Number of admissions
Number of prescribers
Number of wards
Average variation of INR from normal range
Average variation of APTT from normal range
Average variation of Fibrinogen from normal range
Average variation of PT from normal range
For every increase in prescriber, 5 additional coagulation studies were ordered.
What are the financial benefits realised during this time?

23. Problem Identification
Urine Cultures
Problem Identification
High volume of urine cultures being processed in the microbiology labs in addition to
High volume of repeat tests
Poor reporting of indications for why urine culture has been ordered
High rate of contaminated samples
Inconsistent urine sample collection techniques
What are the financial benefits realised during this time?

24. Behaviour Change Strategies
Urine Cultures
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Personalised ED clinician feedback

25. Behaviour Change Strategies
Urine Cultures
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Personalised ED clinician feedback
Policy & Guidelines
Development of pathology & procedure guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system

26. Behaviour Change Strategies
Urine Cultures
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Personalised ED clinician feedback
Education & Peer Support
Lunch time education sessions
Hub campaigns
Links to literature via Hub page
ATLAS Learning module
Educational posters in ED
Policy & Guidelines
Development of pathology & procedure guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system

27. Behaviour Change Strategies
Urine Cultures
Behaviour Change Strategies
Quality & Audit
Hospital wide audit of test ordering by clinical group
Pre- and post-intervention audit and feedback
Personalised ED clinician feedback
Education & Peer Support
Lunch time education sessions
Hub campaigns
Links to literature via Hub page
ATLAS Learning module
Educational posters in ED
Informatics
Pop-up messaging with the ordering of Urine Cultures on CERNER
Link to new guideline and flowchart upon ordering of Urine Cultures
Policy & Guidelines
Development of pathology & procedure guidelines
Development of Decision Support Tool
Linking of guideline document to online ordering system

28. Results – Hospital Wide
Urine Cultures
Results – Hospital Wide

29. Urine Cultures
Results - ED

30. Promotional Strategies
Urine Cultures
Promotional Strategies

31. Urine Cultures
Decision Support Tool

32. Results Results Urine Cultures Pre-intervention Post-intervention
Volume of tests across whole hospital
Weekly mean =
Weekly mean = 250
↓ p<0.05
Volume of tests in ED
Weekly mean =
Weekly mean = 87.69
Volume of tests per patient whole hospital
0.09
0.06
↓ 32.8%
Volume of tests per patient in ED
0.08
0.04
↓ 45.8%
Audit: Indications for coagulation study ordering
↓ 2 out 5 audit units reported a decrease in orders with no indication

33. CRP
Results - ED
What are the financial benefits realised during this time?

34. Results – Hospital Wide
CRP
Results – Hospital Wide
What are the financial benefits realised during this time?

35. Organisation-wide Activities
Updated governance and procedures for Care Set and Order Set development
Nursing, Medical and Consumer surveys
Monthly newsletters
Dedicated intranet page
MDRP Student Projects – Developing adaptive learning platforms
GP newsletter articles and meeting presentations
Creating links with new projects
Discharging Wisely
Testing Wisely – Frequency of discordance HER2 results
Library strategy

36. Organisation-wide Activities
63% of surveyed staff were aware of Choosing Wisely and the 5 Questions for Consumers
78% believe Choosing Wisely to be a worthwhile investment
65% would feel comfortable encouraging the use of the 5 Questions
84% had heard Choosing Wisely discussed at hospital meetings
Top 3 Enablers for Conversation between Patient and Clinicians
1. More Time
2. More information
3. Clinician Skill
75% of consumers felt that the 5 Questions for consumers had utility in the consultation space
84% felt comfortable asking their health professionals about necessary care
89% of consumers had their last test at the hospital initiated by the clinician
84% would use the Urine Culture poster to guide them on the correct way to collect a sample
Top 3 Barriers to Asking their Clinician Questions
1. Insufficient appointment time
2. Trust the doctor‘s expertise
3. Worried about taking up doctor time
Library strategy

37. Sustainability Strategies
Library strategy

38. Sustainability Strategies
Library strategy

39. Lessons Learnt Multi-disciplinary engagement and motivation
Culture change
Making successful changes part of everyday practice
Importance of robust data systems
Ongoing monitoring and feedback
Active engagement with established systems:
Intern orientation and education curriculum
Research Week
QI activities across the hospital

40. Next steps
State-wide leadership through the Choosing Wisely Scaling Collaboration
EOI process will commence early 2018 for 10 health services to join the collaborative
Focus of the collaborative will be reducing unnecessary pathology and imaging tests through empowering and guiding health services in the principles of Choosing Wisely